Alternate Formats

Form 2: Wound Assessment: Ulcer Information

On-Time Pressure Ulcer Healing Project

Describes new tools to document pressure ulcer healing and treatments as part of the On-Time Quality Improvement Program.

Patient ID:

Facility Name _______________________________________

Date of Admission: __ __ /__ __ /__ __ __ __ M M D D Y Y Y Y

Resident ID: _____________________________________

Date Ulcer Identified: MM/DD/YYYY

Initial Stage:(at time ulcer first identified)

I __ II ___ III ___ IV ___ Unstageable ___

Multiple Ulcers ID Number

Multiple Ulcer ID: Ulcers will be uniquely identified for reporting. Use this section if you can answer 'yes' to 1 AND 2 below:1. There are two or more ulcers on the same ulcer location and2. Multiple ulcers on the same location were identified on the same date, e.g. same onset date